Maintaining compliance with Joint Commission standards can be a complex and challenging task. Many organizations look for tools to assist in that process. You need only look as far as your JC extranet site to find one such tool-the Periodical Performance Review (PPR).
Q How can the PPR assist in our quest for continuous compliance?
A The PPR process occurs annually, which allows your organization to stay current with compliance issues and track and monitor progress toward attaining and maintaining standards compliance. By utilizing the PPR as a management tool, your organization will begin to incorporate Joint Commission standards into your day-to-day operations, which facilitates a continuous state of readiness.
Q What are the requirements?
A There are four PPR options available.
[black diamond] The Full PPR requires a thorough self-assessment utilizing the PPR tool to identify areas of noncompliance and opportunities for improvement. Plans of action (POAs) and measures of success (MOSs) are developed and entered into the tool, which is then electronically submitted to the Joint Commission for review. If a conference call is requested by your organization, the Standards Interpretation Group (SIG) will discuss your findings and provide approval for your POAs and MOSs.
[black diamond] Option 1 involves your organization determining that for substantive reasons, it's legal counsel advises them not to submit the full PPR. The organization must attest that while it won't be submitting it, it has completed the PPR and any necessary POAs and required MOSs. No report is submitted, and consequently, no review is done by the Joint Commission.
[black diamond] Option 2 also requires the organization to attest that after legal consideration, it opts not to submit the full PPR, and instead chooses to undergo a limited PPR onsite survey. The surveyor leaves a written report with the organization. Your organization must submit its POAs and MOSs to the Joint Commission. A conference call is required for approval of POAs and MOSs.
[black diamond] Option 3 is identical to Option 2 with one exception. In Option 3, the report is presented verbally. As such, no report is submitted to the Joint Commission and no review for approval takes place.
Q Why do we need to have a conference call in order to receive approval of our plans?
A The conference call provides the opportunity to discuss your findings, plans, and measures with the SIG. Plans should be specific to the issue. MOSs should be quantifiable and measurable, identify numerator and denominator, and include sample size, frequency of measurement, and compliance threshold goal.
You may be able to challenge specific findings that are cited during your full survey if the issues are the same and your plans and implementation dates are acceptable. Ask your surveyor to flag your survey report. SIG staff will review the report along with PPR information and make a determination. If you've had your conference call, action may be taken based on when the survey falls in relation to the implementation dates. If you haven't yet had your conference call, action may be taken based on the defined plans, measures, and implementation dates. Finally, if your survey takes place after your conference call and defined implementation dates, track record dates will change based on approved implementation dates.